Stefan Sjöström

Why community compulsion became the solution - Reforming mental health law in Sweden.

The aim of this article is to understand how compulsory community care (CCC) has become a solution in mental health policy in so many different legal and social contexts during the last 20 years. The recent introduction of CCC in Sweden is used as a case in point, which is then contrasted against the processes in Norway, England/Wales and New York State. In Sweden, the issue of CCC was initiated following high-profile acts of violence. Contrary to several other states, there was agreement about the (lack of) evidence about its effectiveness. Rather than focusing on dangerousness, the government proposal about CCC was framed within an ideology of integrating the disabled. The new legislation allowed for a broad range of measures to control patients at the same time as it was presented as a means to protect positive rights for patients. Compared to previous legislation in Sweden, the scope of social control has remained largely the same, although the rationale has changed - from medical treatment via community treatment and rehabilitation, to reducing the risk of violence, and then shifting back to rehabilitation in the community. The Swedish approach to CCC is similar to Norway, while New York and England/Wales have followed different routes. Differences in ideology, social control and rights orientations can be understood with reference to the general welfare and care regimes that characterize the four states.

Stories of Rediscovering Agency Home-Based Occupational Therapy for People With Severe Psychiatric Disability

As part of a larger study, we offered Everyday Life Rehabilitation (ELR) as a model for integrated occupational therapy in sheltered or supported housing facilities, to enable meaningful daily occupations for people with psychiatric disabilities. Our aim with this study was to understand how participants made sense of their occupational transformations in the context of their everyday life and life history. We carried out qualitative interviews and field observations with 16 participants with psychosis-related disorders. We used narrative analysis and disclosed stories of “rediscovering agency,” referring to occupational and identity transformations. A parallel outcome study has shown positive results for participants, and by using narrative inquiry we contribute with a deeper understanding of the meaning making of their transformations and mechanisms of the intervention; i.e., hope, extended value of reaching goals, reentering the majority world, transparency of process, and attunement to the individual. The findings support the use of the ELR intervention.

Home bittersweet home: the significance of home for occupational transformations

Background: The study illuminated how persons with psychiatric disabilities experienced the processes of change in a residential context. Material: Qualitative interviews with residents living in supported housing were conducted and analyzed using constant comparative analysis. Discussion: Residential conditions appear to provide a complex structure that facilitates rehabilitative interactions, in which ‘progressive tensions’ arise between opposing values, such as authentic versus artificial, and independence versus dependence, both of which are important in the process of change. Conclusions: A client-centred approach could be taken further if clients are engaged in productive discussions about challenging these ‘progressive tensions’. Awareness of the meaning of home also emerged as central.

The compliant court : Procedural fairness and social control in compulsory community care

Compulsory community care (CCC) was introduced in Sweden in 2008. This article investigates all written court decisions regarding CCC over a 6 month period in 2009 (N=541). The purpose is to examine how the legal rights of patients are protected and what forms of social control patients are subjected to. 51% of CCC patients are women and 84% are being treated for a psychosis-related disorder. In the court decisions, only 9% of patients are described as dangerous to themselves, while 18% are regarded a danger to others. The most common special provisions that patients are subjected to are medication (79%) and a requirement that they must maintain contact with either community mental health services (51%) or social services (27%). In the decisions, both the courts and court-appointed psychiatrists agree with treating psychiatrists in 99% of cases. Decisions lack transparency and clarity, and it is often impossible to understand the conclusions of the courts. There is considerable variation between regional courts as regards the provisions to which patients are subjected and the delegation of decision-making to psychiatrists. This means that decisions fail to demonstrate clarity, transparency, consistency and impartiality, and thus fail to meet established standards of procedural fairness. Surveillance techniques of social control are more common than techniques based on therapy or sanctions. Because of the unique role of medication, social control is primarily imposed on a physical dimension, as opposed to temporal and spatial forms. The article concludes that patients are at risk of being subjected to new forms of social control of an unclear nature without proper legal protection.

Translating Coercion Policy into Inter-Organisational Collaboration : The Implementation of Compulsory Community Care for People with Mental Illness

In 2008, compulsory community care (CCC) for people with severe mental illness was introduced in Sweden. CCC requires co-operation between psychiatric and social services, thus further complicating ...